Chapter 7
Medicare Outpatient
Medicare Outpatient
Fee Schedule
Prospective Payment (case rate)
Reasonable Cost Payment
What are the 3 reimbursement methodologies used in OPPS?
The 2 parts of the Medicare Physician & Other Health Professional Payment System
What are RBRVS & MPFS?
Responsible for obtaining a prior authorization for services.
Who is the physician office or hospital staff?
HCPCS
What is Healthcare Common Procedure Coding System?
This party or entity that uses the scrubber.
What is a hospital?
This is the complexity of a hospital's mix of patients.
What is CMI (Case Mix Index)?
A payment status indicator used to identify services that are packaged.
What is status indicator "N"?
What commercial payers use to adjust to the MPFS in order to meet their needs.
What is modifying the conversion factor?
Contacting the provider to schedule services such as an office visit or surgical procedure.
What are Scheduling Services?
Accounting for all reportable services and supplies rendered to a patient.
What is charge capture?
Benefit statement used by Medicare.
What is the Medicare Summary Notices?
DNFS
What is Discharged Not Final Billed?
Status Indicator for Inpatient Only Procedures?
What is status indicator "C"?
When calculating MPFS amounts, these RVU elements are adjusted by GPCI.
What are WORK, PE and MP?
Provides information on healthcare payment plans or healthcare loans.
What is financial counseling?
The dollar amount that the hospital requests for payment when providing treatment to the patient.
What is the charge?
The preferred accounting practices for the healthcare industry.
What is accrual accounting?
PEPPER
What is Program for Evaluating Payment Patterns Electronic Report?
A comprehensive APC Payment that all services are packaged with.
What is status indicator J1?
GPCI
What is Geographic Practice Code Indexes?
The collection of data including medical history and insurance information.
What is Registration?
Data table to manage required billing elements for services provided to patients.
What is the Charge Description Master?
The internal auditing system.
What is the Scrubber?
KPI
What are Key Performance Indicators?
This APC Component is a measure of the resource intensity of a particular procedure or service.
What is the Relative Weight?
RVUs
What are Relative Value Units?
The statue that prohibits Medicare beneficiaries from using drug copay cards.
What is the Anti-kickback statue?
Unique identifier for all services and supplies included in the CDM.
What is the charge code?
The allowable charge is comprised of benefit amount and this element.
What is the cost-sharing amount?
Productivity
Accuracy
Query Appropriateness
What are the 3 main performance criteria?